Is skin exposure to water mainly occupational or nonoccupational? A population-based study

BACKGROUND

Skin exposure to water is considered to contribute to hand eczema. Knowledge about total water exposure during a day is scanty.

OBJECTIVES

To investigate self-reported water exposure at work as well as throughout the day.

METHODS

Skin exposure to water was assessed from two questionnaire-based health surveys: the nationwide Environmental Health Survey 2007 (EHS), which enquired about water exposure throughout the day, and the Stockholm Public Health Survey 2006 (PHS), which probed water exposure at work. Answers from 19,667 individuals (EHS) and 18,318 individuals (PHS) were available for analysis.

RESULTS

In total, 22% of respondents (women 30%, men 12%) reported skin exposure to water more than 20 times during an entire day (EHS) compared with 6% (women 8%, men 4%) at work (PHS). In a univariate analysis, using a merged file comprising data from the EHS and the PHS, water exposure more than 20 times a day was more common in the EHS (prevalence proportion ratio 3·570, 95% confidence interval 3·353-3·802). In multivariate models the variables studied did not fulfil the criteria for being confounders. Water exposure at work declined with increasing age in both women and men (P < 0·0001) as did water exposure during the entire day in men (P < 0·0001). However, women were equally exposed during the entire day across age groups (P = 0·205).

CONCLUSIONS

High water exposure over the entire day was found to be considerably more frequent than exposure at work. Thus, a significant proportion of water exposure seems to occur outside work. This should be considered in prevention of hand eczema and when counselling patients with hand eczema in clinical practice.

Occupational skin disease in Sweden - a 12-year follow-up

The aim of this project was to study the long-term prognosis of occupational skin diseases in Sweden. In 1999, a questionnaire was sent to 623/655 individuals who in 1987 reported occupational skin disease to the Social Insurance Office. 394 answered the questionnaire, and 123 non-responders were interviewed by telephone, giving 517 participants (83%), 323 females and 194 males. 85% reported skin symptoms after 1987, 70% during the previous year. 28% considered themselves recovered, of those with nickel allergy only 12%. In a logistic regression model, skin atopy was the strongest unfavourable factor for the prognosis followed by contact allergy and female sex. 66% had consulted a doctor after 1987 and the majority, 82%, had performed occupational changes - most common was change of jobs, 44%. Those who had changed jobs reported less sick leave. The conclusion is that occupational skin diseases have a clear tendency to end up as chronic conditions with a majority reporting symptoms at a 12-year follow-up. The skin disease had influenced the occupational situation for the majority (82%) and for 15% resulted in exclusion from the labour market through unemployment or disability pension.

Fifteen-year follow-up of hand eczema: persistence and consequences

BACKGROUND

Hand eczema is a skin disease often with a long-lasting and relapsing course. The long-term prognosis in the general population is unknown.

OBJECTIVES

The aims were to examine the extent to which hand eczema had persisted and the medicosocial consequences of the disease.

METHODS

In a 15-year follow-up of hand eczema, patients diagnosed in a previous population-based study were sent a questionnaire with 20 questions concerning the persistence and course of the disease, and its occupational and medicosocial consequences.

RESULTS

Addresses were available for 1115 persons, of whom 868 answered the questionnaire. Sixty-six per cent of the respondents reported periods of hand eczema and 44% reported symptoms during the previous year, with no sex difference. Twelve per cent reported continuous eczema. However, 74% of those reporting symptoms considered that their hand eczema had improved; of these more were women than men (78% vs. 66%, P < 0.01). Twenty people, 3% of those who were gainfully employed in 1983, reported a change to another occupation because of their hand eczema, 15 of these reporting improvement after the job change. A considerable need for medical consultation was reported, as was the influence on psychosocial functions among those who had eczema the previous year, e.g. sleep disturbances (36%) and hampered leisure activities (72%). Job changes related to hand eczema and psychosocial impairment were also reported by individuals who had not sought medical help for their hand eczema.

CONCLUSIONS

This study demonstrates a variable and poor long-term prognosis for hand eczema in the general population. One-third sought medical care during follow-up, while the vast majority with ongoing hand eczema experienced negative psychosocial consequences. For about 5%, the hand eczema gave far-reaching consequences including long sick-leave periods, sick pension and changes of occupation.

Hand eczema in 45 bakers - a clinical study

The skin of bakers is heavily exposed to dough, spices, water and detergents. This is follow-up of a previous Swedish questionnaire study showing bakers to have a 3-fold increased risk of hand eczema. The aims were to establish diagnoses and to study consequences of hand eczema. From a cohort study of 2226 bakers, a random sample among bakers reporting hand eczema was examined. Of 60 randomly selected bakers reporting a history of hand eczema, 52 attended an examination comprising a standardized interview, documentation of clinical skin signs, patch testing and prick testing with standard and bakery series, and serum analyses. In all, 45 bakers confirmed a history of hand eczema, for which 11 (24%) had been on sick leave, with a median duration of 14 weeks. 13 (29%) had changed their occupation due to skin disease, 19 had positive patch test reactions to standard contact allergens - and 5 to bakery contact allergens. 16 bakers had positive prick tests to standard allergens, 10 to bakery allergens, of whom 9 reacted to flours. Since considerable medical and social consequences of hand eczema are seen, thorough diagnosis of contact allergy and IgE-mediated allergy in bakers, as well as preventive measures, are essential.

Occupational dermatitis in dental personnel: contact dermatitis with special reference to (meth)acrylates in 174 patients

Between 1995 and 1998, 174 dental personnel were referred as patients to the Department of Occupational and Environmental Dermatology, Stockholm. After clinical examination, 131 were patch tested with the Swedish standard series and 109 with a dental screening series. Furthermore, 137 were tested for IgE-mediated allergy to natural rubber latex (NRL). Hand eczema was diagnosed in 109/174 (63%), 73 (67%) being classified as irritant contact dermatitis and 36 (33%) as allergic. Further diagnoses included other eczemas, urticaria, rosacea, psoriasis, tinea pedis, bullous pemphigoid or no skin disease. 77/131 (59%) had positive reactions to substances in the standard series and 44/109 (40%) to substances exclusive to the dental series. 24/109 (22%) patients had positive reactions to (meth)acrylates, the majority with reactions to several test preparations. Reactions to HEMA (2-hydroxyethyl methacrylate), EGDMA (ethyleneglycol dimethacrylate) and MMA (methyl methacrylate) were most frequent. 9 of the 24 were positive only to (meth)acrylates, the remaining 15 also had reactions to allergens in the standard series. 23 of these had hand eczema and 1 facial eczema. In 17 of the 24 allergic to (meth)acrylates, the dermatitis had started in 1995 or later, in 15 within the previous 12 months. Of 8 who had been sick-listed, 7 also had a history of atopy and 6 were allergic to nickel. The most frequent allergens besides (meth)acrylates were nickel, cobalt, palladium, fragrance mix, colophonium and thiuram mix. Allergy to natural rubber latex was diagnosed in 14/137 (10%). In conclusion, irritant hand dermatitis was the dominant diagnosis. Contact allergy to (meth)acrylate was seen in 22% of the patch tested patients, with reactions to 3 predominant test substances. 1/3 of the patients with allergy to (meth)acrylates had been sick-listed for dermatitis, but in all these cases the (meth)acrylate allergy was seen together with atopy and/or further contact allergies.

Protective gloves in Swedish dentistry: use and side-effects

BACKGROUND

During the 1980s routine wearing of gloves in dentistry was recommended by health authorities in several countries. However, prolonged glove use is associated with side-effects of irritant and allergic origin.

OBJECTIVES

To investigate the extent of glove use and self-reported glove intolerance reactions among Swedish dentists, and to examine how far IgE-mediated allergy to natural rubber latex (NRL) occurs in subjects who report rapid itching when in contact with protective gloves.

SUBJECTS/METHODS

A postal questionnaire was answered by 3083 of 3500 licensed dentists, a response rate of 88%. Of the dentists who reported rapidly occurring itching of the hands from gloves, 131 of 170 attended a clinical examination including a skin prick test (SPT) and a serological examination (RAST) for IgE-mediated allergy.

RESULTS

Seventy-three per cent of the dentists reported daily glove use of more than 2 h, 48% more than 6 h a day, and 6% reported no use. NRL gloves were used most frequently (P < 0.001) and were the main material that elicited symptoms (P < 0.001). Female dentists reported more frequent glove use than males, as did young dentists (P < 0.001) compared with older ones. Females also preferred vinyl gloves. Glove intolerance reactions were reported by 723 (23%) dentists, [females 28%, males 21% (P < 0.001)] and were more common in younger dentists. Of the 417 dentists with reported hand eczema during the previous year, 54% reported glove intolerance, compared with 20% of the dentists without hand eczema (P < 0.001). A logistic regression analysis including hand eczema, age, sex and atopy showed that all these factors contributed significantly to the risk of glove intolerance, and that hand eczema was a stronger factor than atopy. In 15 of 131 (11%) dentists examined for reported glove-related itch, latex allergy was verified by SPT and/or RAST. Glove-related conjunctivitis, rhinitis and asthma, in contrast to skin symptoms, showed a significant association with IgE-mediated allergy to NRL.

CONCLUSIONS

Swedish dentists show good compliance with the recommendations for routine glove use. Intolerance reactions are frequently reported, especially by dentists with hand eczema, which emphasizes the need for preventive skin care programmes. Glove-related symptoms from mucous membranes showed a higher association with IgE-mediated allergy to NRL than reported itching of the skin, a fact that should be considered when composing screening questionnaires for NRL sensitization

[Task and task time should dictate the choice of gloves in health care services]

Worldwide consumption of medical gloves increased during the 1980's due to the recognized risk of cross infections in medical and dental care. In Stockholm County Council around 1 million pairs of surgical gloves and 18 millions pairs of examination gloves are purchased per year. In the following paper different glove materials and types are presented and also regulations on use and purchase. The protective capacity of gloves and contact hypersensitivity reactions are also discussed and advice is provided on glove usage.

Contact allergy and hand eczema in Swedish dentists

Hand eczema and contact allergy in Swedish dentists were studied in a multidisciplinary project. The aims of the study were to establish diagnoses, to investigate the occurrence of contact allergy, in particular to (meth)acrylates, and to evaluate certain consequences of hand eczema. A postal questionnaire on skin symptoms, atopy and occupational experience was mailed to 3,500 dentists aged <65 years, and licensed 1965-1995. The response rate was 88%. Among dentists living in 3 major cities, 14.9% (n= 191) reported hand eczema during the previous year. They were invited to a clinical examination, including patch testing with a standard and a dental series. 158/191 (83%) dentists attended, and hand eczema diagnosis was confirmed in 149/158 (94%). Irritant contact dermatitis was diagnosed in 67% and allergic contact dermatitis in 28%. On patch testing, 50% presented at least 1 positive reaction. The most frequent allergens were nickel sulfate, fragrance mix, gold sodium thiosulfate and thiuram mix. 7 (5%) had positive reactions to (meth)acrylates, all to 2-hydroxyethyl methacrylate and 6 also to ethyleneglycol dimethacrylate. 38% had consulted a physician, 4% had been on sick-leave and 1% had changed occupational tasks due to hand eczema. No dentist with allergy to acrylates had been on sick-leave or changed occupation. It is concluded that dentistry is a high-risk occupation for hand eczema, and that irritant contact dermatitis is most common. The prevalence of contact allergy to acrylates was below 1% in the population of responding dentists, and in most cases did not have serious medical, social or occupational consequences.

Routine patch testing with the sesquiterpene lactone mix in Europe: a 2-year experience. A multicentre study of the EECDRG

To test the screening value of the sesquiterpene lactone (SL) mix in Europe today and describe epidemiological and clinical features of Compositae-sensitive patients, the SL mix 0.1% pet. was included in the standard patch test series in 11 European clinics. 10,695 patients were tested, and 106 (1%) had positive reactions, 74% of which were of current or old relevance. The prevalence of positive reactions varied between 0.1 and 2.7% in different centres. The median age of the 66 females was 51.5 years, and 55.2 in the 40 males. The 20 occupationally sensitized had a higher % of males and a median age of 43 years, whereas 7 UV-sensitive patients had a median age of 72 years. Garden plants were the major suspected sensitizers and the clinical patterns were partly, in accordance with plant dermatoses in general, involving hands, forearms and face, and partly widespread eczema in a large proportion of the patients. More than 1/3 were positive to perfume and/or colophony, possibly reflecting cross-reactivity. With only 1 case of active sensitization and no irritant reactions, the SL mix is a safe allergen and the overall prevalence of positive reactions supports its continued use in the standard patch test series.

Latex allergy from glove powder--an unintended risk with the switch from talc to cornstarch?

The present study aimed to investigate to what extent glove powders of different origins and brands bind and release latex allergens. One mineral talc and five cornstarch powders were used. The allergenic material was sap of Hevea brasiliensis. The powders were incubated together with the natural rubber latex sap, and four series of experiments were performed. The talc showed the highest tendency to bind isotope-labeled proteins. When incubated with a latex allergen solution, it reduced free allergen from 100 to 2 units/ml compared to a reduction to 70-98 units/ml for the cornstarch powders. In contrast to the nonstable binding of allergen to cornstarch, the binding to talc was irreversible. The allergen bound to talc was allergenically intact and, when incubated with serum, reduced the concentration of free IgE antibody to latex to 10% of the initial level. Mineral talc had a high capacity to bind latex allergens firmly. In contrast, cornstarch captured the latex allergen, but the binding seemed less pronounced and was unstable. The replacement of talc by cornstarch as glove-donning powder has coincided with the rapid increase in latex allergy. Mineral talc is heavy and only transiently airborne. Could this difference between talc and cornstarch in latex-allergen-binding pattern and the tendency of the latter to be airborne play an important role in the bioavailability of latex allergen and thus in the epidemic of latex sensitization.

Reduction of latex-allergen content in Swedish medical catheter balloons--a survey of 3 years' production

Anaphylactic reactions after intravascular exposure to natural rubber latex (NRL) have been reported. Thus, there is an urgent need to produce medical devices with the lowest possible latex-allergen content. The latex-allergen concentration in extracts prepared from 92 lots of medical catheter (MC) balloons, manufactured by Nolato Polymer AB, Torekov, Sweden, from April 1993 to March 1996, was measured with an EAI (IgE antibody inhibition) assay. Inhibitory capacity was expressed in arbitrary units/ml (U/ml) in relation to reference NRL sap, given an arbitrary value of 1000 U. Extracts from randomly selected lots were measured for protein by the modified Lowry method. Water leaching, chlorination, and treatment with savinase were used experimentally to study reduction of the latex-allergen content. The latex-allergen content in extract from the regular MC balloons varied from 0.1 to 2.9 U/ml. All the methods used to reduce the allergen content were effective, and increased leaching stabilized the allergen content at a low level. The protein concentration of the extracts varied between 9 and 100 mg/l. No correlation was found between protein and allergen content. As a result of this study, the manufacturer has extended the stage of water leaching in the production process. This study shows that cooperation between immunologists and manufacturers may result in product development and improvement.

The value and limitations of protective gloves in medical health service: Part III

The value of protective gloves in the health care environment is well known. However, these gloves are not perfect. Some are permeable to microorganisms and various chemicals, and/or result in side effects for health care professionals. Gloves that offer the greatest protection and least side effects are highly desirable. Limitations of glove use due to side effects, and glove selection and therapeutic alternatives are described in Part III of this three-part series.

The value and limitations of protective gloves in medical health service: part II

The value of protective gloves in the health care environment is well known. However, these gloves are not perfect. Some are permeable to microorganisms and various chemicals, and/or result in side effects for health care professionals. Gloves that offer the greatest protection and least side effects are highly desirable. Protection against microorganisms and protection against chemicals used in health care are described in Part II of this three-part series.

The value and limitations of protective gloves in medical health service: Part I

The value of protective gloves in the health care environment is well known. However, these gloves are not perfect. Some are permeable to microorganisms and various chemicals, and/or result in side effects for health care professionals. Gloves that offer the greatest protection and least side effects are highly desirable. Field of application rules and regulations, materials and manufacturing, and test methods of protective gloves are described in Part I of this three part series.

Latex allergens in glove-powdering slurries

Exposure to airborne glove powder contaminated with latex allergens is known to provoke respiratory symptoms in latex-sensitized individuals. In the commonly used wet-powdering process in glove manufacturing, powder is applied by dipping gloves in a cornstarch suspension, a slurry. The slurry is a potential source of allergen contamination of the powder. The protein and latex allergen contents in five different slurries and in extracts from the corresponding latex gloves were measured using the BCA assay and the IgE antibody inhibition assay (EAI assay). Latex allergens were found in all slurries and gloves. No correlation between the values of protein contents and allergen contents was found. Wet powdering of gloves induces a risk of latex protein contamination of the cornstarch.

Nasal peak-flow-rate recording is useful in detecting allergic nasal reactions--a case report

Serial nasal peak-expiratory-flow-rate recordings have been used to detect changes in nasal patency. A hospital nurse with allergy to latex showed a marked decrease in nasal flow when exposed to latex gloves in a challenge test and in her work environment. We propose using the method as a diagnostic tool for allergic rhinitis in occupational and other exposure situations in which nasal blockage is a prominent symptom.

Glove-related skin symptoms among operating theatre and dental care unit personnel (II). Clinical examination, tests and laboratory findings indicating latex allergy

Following interviews on glove-related skin symptoms, 202 subjects, 56 hospital workers at an operating theatre and 146 workers at dental care centres, were skin prick tested with different latex extracts. Also, in 193 cases, blood samples were RAST-analysed, using the CAP system. Sensitization to latex diagnosed by positive skin prick test and/or by demonstration of specific antibodies in serum analyses was found in 3.5% of the subjects investigated. 4 cases (2%) showed 1 or more positive skin tests, and 4 cases (2%) had positive RAST to latex antigens. Further work on the diagnostic tools is still needed, as are prognostic studies.

Glove-related skin symptoms among operating theatre and dental care unit personnel (I). Interview investigation

233 employees in hospital and dental care participated in an interview investigation on glove-related skin complaints. 37% (87/233) reported skin symptoms related to glove use. 2% (4/233) reported localized contact urticaria provoked by latex gloves, 10% (23/233) hand eczema and 24% (56/233) unclassifiable skin intolerance reactions from gloves. Another 2% (4/233) reported facial irritation from gloves. Glove-related skin symptoms were thus reported by more than 1/3 of the personnel and the reported glove-provoked contact urticaria constituted 5% (4/87) of the intolerance reactions.

Nail varnish allergy with far-reaching consequences

Contact allergy to nail varnish is well-known, and toluene-sulphonamide formaldehyde resin (TSAfr) was identified as the main allergen in 1943. During the period October 1989-December 1991 we identified 18 cases of contact allergy to nail varnish. The aim of the study was to describe the clinical picture, patch-test results, course and socio-medical consequences. Seventeen of the 18 patients were patch-test positive to TSAfr and 17/18 were positive to their own nail varnishes. Fourteen of the 18 were also positive to one or more substances in the standard patch-test series. The lesions were scattered, involving the face, eyelids, neck and hands. Periungual lesions were recorded in 11/18. The dermatitis resolved within a few weeks when the use of nail varnish was stopped. The socio-medical consequences of contact allergy to nail varnish had been severe: sick leave (nine cases), hospitalization (four cases), cessation of visual-display-unit (VDU) work (two cases), and job-loss (two cases). Our conclusions are that contact allergy to nail varnish and TSAfr is common; the socio-medical consequences may be severe; periungual lesions occur more frequently than previously stated, and the presence of other contact allergies makes the diagnosis easy to miss. TSAfr should be included in the standard patch-test series and patients should also be tested with their own nail varnishes. The study illustrates the need for mandatory declaration of the ingredients of cosmetics, as is required in the U.S.A.

Contact allergy to Compositae plants in patients with summer-exacerbated dermatitis

16 patients with summer-exacerbated dermatitis were examined by patch testing and photopatch testing with a battery of Compositae and standard allergens. IgE and RAST, and the thresholds to UVA and UVB, were determined. 6 female and 2 male patients showed allergic contact reactions to one or more Compositae extracts from flowers common in Sweden, also used in skin care products. The study points to the importance of including testing with Compositae allergens in patients with summer-exacerbated dermatitis. This group comprises patients with multiple contact reactions, photosensitivity and flares of atopic dermatitis.

IgE-mediated allergy to natural rubber in 30 patients with contact urticaria

30 patients who had experienced contact urticaria after exposure to gloves, contraceptives, balloons or dental cofferdams went through a detailed examination including interviews on: exposure to rubber; local and distant symptoms; provocation tests; skin prick tests with (among other substances) latex extracts from the rubber tree Hevea brasiliensis; patch testing, IgE and RAST analyses. 23 patients (77%) reported additional symptoms from distant organs. 13 belonged to medical occupations; 25 were classified as atopics based on history; 21 had raised IgE-values; 25 were RAST-positive to the extracts from Hevea brasiliensis. 13 had a pre-existing hand dermatitis, of whom 6 were patch test positive to standard allergens. Skin prick tests with extracts from Hevea brasiliensis were the most sensitive diagnostic tool, while the RAST analysis was positive in 25/30 cases. These tests and analyses including RAST were negative in 40 control subjects. Provocation tests are of great value, but difficult to standardize. Several patients reported severe reactions at medical and dental examination/treatment situations (surgical gloves, dental cofferdams), and the risk of life-threatening anaphylactic reactions is emphasized.

Anaphylaxis and angioedema due to rubber allergy in children

Delayed hypersensitivity to rubber chemicals is well known but there are an increasing number of case reports on an immediate type of hypersensitivity inducing contact urticaria and anaphylaxis in adults. We now report on three atopic children who developed angioedema, which in two of them progressed to anaphylaxis after exposure to natural rubber products. All three patients showed positive skin prick tests and one had a positive RAST test to latex from the rubber tree (Hevea brasiliensis). It is clear that sensitized subjects are at risk of developing anaphylaxis when exposed to natural rubber products, e.g. during medical examination or surgery when rubber gloves are used.

A double-blind study of Grenz ray therapy in chronic eczema of the hands

The effect of Grenz ray therapy as an adjunct to topical therapy in chronic symmetrical eczema of the hands was assessed in 24 patients by randomly allocating active treatment to one hand while the other, which received simulated therapy, served as a control. Three Gy of Grenz rays were applied on six occasions at intervals of 1 week. There was a significantly better response to active treatment 5 and 10 weeks after the start of treatment compared with the untreated control.

IgE-mediated anaphylactoid reactions to rubber

Delayed hypersensitivity to rubber chemicals is well known, but there are only a limited number of case reports on an immediate type of hypersensitivity inducing contact urticaria. We have recently seen several patients with rubber glove-induced contact urticaria who have had both positive skin prick tests and positive RAST tests to natural latex from the rubber tree (Hevea brasiliensis). We now report on five patients who also developed systemic reactions. It is clear that sensitized subjects are at risk of developing anaphylaxis during medical examination or surgery when rubber gloves are used. The occurrence of IgE-mediated allergy to rubber is probably underestimated.

Discomfort from rubber gloves indicating contact urticaria

Rubber glove intolerance is a common dermatological problem and hypersensitivity of both delayed and immediate types occur. In order to study immediate skin reactions induced by rubber gloves, 15 patients with discomfort and itch produced by rubber gloves were examined. The patients were provoked by wearing rubber gloves, scratch tested with gloves, rubber chemicals and powders. RAST-tests were performed using an extract from the rubber tree (Hevea brasiliensis). In 6/15 patients, contact urticaria was confirmed, in 3 of whom IgE antibodies to latex were demonstrated.

Skin irritancy from nonanoic acid

100 hospitalized patients with skin disease were patch tested with graded dilutions of nonanoic acid (NON), sodium lauryl sulfate (SLS) and benzalkonium chloride (BENZ). Smooth dose-response curves were obtained. The concentration needed to produce a discernible irritant reaction in 50% of the population (ID50) was found to be lower in cases of irritant than of allergic contact dermatitis; this finding warrants further study. Björnberg's observation that it is not possible to predict the strength of the reaction to one irritant by knowing the strength of the reaction to another was confirmed. Benzalkonium chloride caused a high frequency of pustular and/or bullous reactions with scarring as a sequela. It is suggested that this irritant could be replaced by nonanoic acid in experimental studies of topical irritancy, since the test reactions from nonanoic acid were reproducible, easy to read and left no staining or scarring.